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US Trends in Prevalence, Awareness, Treatment, and Control of Hypertension, 1988-

2008

Context
Hypertension is a major risk factor for cardiovascular disease and treatment and control of
hypertension reduces risk. The Healthy People 2010 goal was to achieve blood pressure (BP)
control in 50 % of the US population.
Objective
To assess progress in treating and controlling hypertension in the United States from 1988-
2008.
Design, Setting, and Participants
The National Health and Nutrition Examination Survey (NHANES) 1988-1994 and 1999-
2008 in five 2-year blocks included 42.856 adults aged older than 18 years, representing a
probability sample of the US civilian population
Main Outcome Measures
Hypertension was defined as systolic BP of at least 140 mmHg and diastolic BP of at least 90
mmHg, self-reported use of antihypertensive medications, or both. Hypertension control was
defined as systolic BP values of less than 140 mmHg and diastolic BP values of less than 90
mmHg. All survey periods were age-adjusted to the year 2000 US population.
Results
Rates of hypertension increased from 23.9% (95% confidence interval [CI], 22.7%-25.2%) in
1988-1994 to 28.5% (95%CI, 25.9%-31.3%; P<.001) in 1999-2000, but did not change
between 1999-2000 and 2007-2008 (29.0%; 95% CI, 27.6%-30.5%; P=.24). Hypertension
control increased from 27.3% (95% CI, 25.6%-29.1%) in 1988-1994 to 50.1% (95% CI,
46.8%-53.5%; P=.006) in 2007-2008, and BP among patients with hypertension decreased
from 143.0/80.4 mmHg (95% CI, 141.9-144.2/79.6-81.1 mmHg) to 135.2/74.1 mmHg (95%
CI, 134.2-136.2/73.2-75.0 mmHg; P=.02/P<.001). Blood pressure control improved
significantly more in absolut epercentages between1999-2000 and 2007-2008 vs 1988-1994
and 1999-2000 (18.6%; 95% CI, 13.3%-23.9%; vs 4.1%; 95% CI, 0.5% to 8.8%; P<.001).
Better BP control reflected improvements in awareness (69.1%; 95% CI, 67.1%-71.1%; vs
80.7%; 95% CI, 78.1%-83.0%; P for trend=.03), treatment (54.0%;95%CI,52.0%-56.1%; vs
72.5%; 95%CI, 70.1%-74.8%; P=.004), and proportion of patients who were treated and had
controlled hypertension (50.6%; 95% CI, 48.0% - 53.2%; vs 69.1%; 95% CI, 65.7% - 72.3%;
P=.006). Hypertension control improved significantly between 1988-1994 and 2007-2008,
acrossage, race, and sexgroups, but was lower among individuals aged 18 to 39 years vs 40 to
59 years (P<.001) and 60 years or older (P<.001), and in Hispanic vs white individuals
(P=.004).
Conclusion
Blood pressure was controlled in an estimated 50.1% of all patients with hypertension in
NHANES 2007-2008, with most of the improvement since 1988 occurring after 1999-2000.
Hypertension control was significantly lower among younger than middle-aged individuals
and older adults, and Hispanic vs white individuals.


Hypertension ia a prevalent condition affecting approximately 65 millionin-dividuals
in the United States based on a preliminary report from the National Health and Nutrition
Examination Survey (NHANES) 2005-2006 and coincident US population estimates. Given
the prevalence and impact of hypertension on health outcomes and disparities, several
national in itiatives developed programs, guidelines, and policies to facilitate hypertension
prevention,detection/ awareness, treatment, and control. Hypertension control (defined as
systolic blood pressure [BP] of <140 mmHg and diastolic BP of <90 mmHg) increased from
10% in NHANESII (1976-1980) to 31.0% in 1999-2000. Another NHANES analysis
reported that hypertension control increased from 25.0% in 1999-2000 to 33.1% in 2003-
2004.A preliminary NHANES 2005-2006 report noted approximately 44% of all adults with
hypertension achieved systolic BP of less than 140 mmHg and diastolic BP of less than 90
mmHg.
The reports indicate progress toward the Healthy People 2010 national objective of
controlling BP in 50% of all individuals with hypertension. However, differences in defining
hypertension control and variable age-adjustment slimit the capacity to assess changes
overtime. Moreover, BP data from NHANES 2007-2008 were recently released.
Our study examined changes in hypertension prevalence, awareness, treatment, and
control for all adults combined and for subsets by age, race/ethnicity, and sex across
NHANES 1988-1994 and 1999-2008.
NHANES 1988-1994 and 1999-2008 were conducted by the US Centers for Disease
Control and Prevention National Center for Health Statistics. NHANES volunteers were
selected using stratified, multistage probability sampling of the non institutionalized US
population. All adults provided written informed consent; the study was approved by the
National Center for Health Statistics Institutional/Ethics Review Board.

Definition
Race/ethnicity was determined by self-report and categorized as non-Hispanic white
(white), non-Hispanic black (black), Hispanic, and other (American Indian, Native Alaskan,
Asian or Pacific Islander, and other race not specified).
Blood pressure in NHANES 1988-1994 and 1999-2008 was measured by physicians
trained in the method using mercury sphygmomanometry and appropriately sized arm cuffs
after volunteers rested 5 minutes seated. Individuals without recorded BP were excluded.
Indetermining mean BP for individuals, the first BP was used if only 1 measurement was
obtained. The second BP was used if 2 readings weretaken; second and third values were
averaged when available. The percent age of individuals with 3 systolic BP readings varied
from 81.5% in 2003-2004 to 99.3% in 1988-1994. The percentage of individuals with 1
systolic BP ranged from 0.2% in 1988-1994 to 7.6% in 2003-2004. The percentage of
individuals with 3 diastolic readings was 0.2% to 0.6% lower than for systolic BP and the
percentage of individuals with 1 measurement was 0.1% to 0.3% higher.
Prevalent hypertension was defined as mean systolic BP of at least 140 mmHg, mean
diastolic BP of at least 90 mmHg, or both, and/or affirming that participants were currently
taking prescription medication to lower BP.
Awareness of hypertension was determined by patients with hypertension responding
affirmatively to the question,Have you ever been told by a doctor or other health care
professional that you had hypertension, also called high blood pressure?
Treatment of hypertension was established by participants responding yes to the
question, Because of your hypertension/high blood pressure, are you now taking prescribed
medicine?
Control of hypertension was defined as systolic BP of less than140 mmHg and
diastolic BP of less than 90 mmHg based on the Fourt hand Fifth Reports of the Joint
National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure.
The Sixth and Seventh JNC Reports retained the same definition of hypertension control
except for lower goals in high-risk subsets, including patients with diabetes. Recent evidence
does not strongly support a systolic BP goal of less than 140 mmHg for patients with
diabetes; therefore, ourstudy focuses exclusively on the goal of systolic BP of less than 140
mmHg and diastolic BP of less than 90 mmHg.
Diabetes Mellitus
Diabetes mellitus was defined by a positive response to any of the questions, Have
you ever been told by a doctor that you have diabetes?; Are you now taking insulin?; Are
you now taking diabetes pills to lower your blood sugar? The definition did not include
patients with only fasting plasma glucose of 126mg/dL or higher (ie, undiagnosed diabetes).

Data Analysis
NHANES Analytic and Reporting Guidelines were followed. SUDAAN version
10.0.1 (Research Triangle Institute, Research Triangle Park, North Carolina) accounts for
NHANES complex sampling design, estimates mean values and percentages, and provides
95% confidence intervals (CIs) (Taylor series linearization).
All surveys were age-adjusted to the US 2000 census. In 2000, 42% of adults were
aged 18 to 39 years, 36% were aged 40 to 59 years, and 22% were 60 years or older, with
weights of 0.42, 0.36, and 0.22, respectively, which were used in calculating prevalence. For
calculating awareness, treatment, and control, additional weights were calculated, because
hypertension prevalence varies by age group. The proportion of adults with hypertension
aged 18 to 39 years, 40 to 59 years, and 60 years or older in each NHANES period was
multiplied by their respective year 2000 weight for all adults. Weights were calculated by
dividing the quotient for each age group by the sum of quotients for all 3 age groups in each
survey.
Weighted linear regression to test time trends from 1988-2008 was performed using
estimated mean values or percentages from SUDAAN as dependent variables and analyzed
with SAS version 9.2 (SAS Institute Inc, Cary, North Carolina). Reciprocals of variances
were used as weights. Time was an independent and continuous variable in regression models
for all patients with hypertension combined and each subgroup. To designate the NHANES
period, 1991 was used for 1988-1994 and 1999, 2001, 2003, 2005, and 2007 for subsequent
surveys. For comparisons among the 3 age and race/ethnicity groups, the Scheffe test was
used to adjust for multiple comparisons. For the 18- to 39-years age group only, weighted
paired t tests comparing 1988-1994 and 2007-2008 were used.
According to NHANES Analytic and Reporting Guidelines, applied in prior reports,
mean estimates with coefficients of variation (CEV) of more than 0.30 are unreliable. Our
main analyses examined changes over NHANES 1988-2008. P values for time trends are not
presented when the weighted least square linear regression CEV exceeded 0.30 or when the
CEV for variables in weighted t tests were more than 0.30. P<.05 defined statistical
significance. Ane Table (available at http://www.jama.com) shows sample sizes for each age
group. Data are presented as means and 95% CIs.

Results
All Adults
Meanage increased with time between 1988-1994 and 2007-2008 (P for trend=.02)
(TABLE 1). The proportion of white individuals decreased marginally (P=.05), black
individuals did not change (P=.85), and Hispanic individuals increased (P=.006). Among all
adults, mean systolic BP did not change (P=.76) and mean diastolic BP decreased (P=.03).
Among individuals without hypertension, mean systolic BP increased from 113.3
mmHg (95% CI, 112.9-113.7 mmHg) in 1988-1994 to 114.8 mmHg (95% CI, 114.1-115.6
mmHg) in 2007-2008 (P fortrend=.02). Mean diastolic BP did not decrease significantly over
time (70.7 mmHg; 95% CI, 70.2-71.2 mmHg; vs 69.2 mmHg; 95% CI, 68.4-69.9 mmHg; P
fortrend=.06).
The proportion of adults with stage 1 hypertension (either systolic or diastolic BP or
both in the range of 140-159/90-99 mmHg; P=.36), prehypertension (systolic/diastolic BP,
120-139/80-89 mmHg; P=.11), and normal BP (<120/<80mmHg, P=.74) did not change
(Table 1). Data were insufficient to evaluate changes in stage 2 hypertension (systolic/distolic
BP, >160/>100 mmHg). Mean body mass index (BMI, calculated as weight in kilograms
divided by height in meters squared) increased over time (P<.001), the percentage of normal
weight individuals (BMI <25.0) decreased (P=.002), and the percentage of obese (BMI
>30.0) (P<.001) and individuals with self identified diabetes increased (P=.01). The
prevalence of hypertension increased from 1988-2008 (P=.01) and between 1988-1994 and
1999-2000 (P<.001) but did not change from 1999-2008 (P=.24) (FIGURE 1).

All Patients With Hypertension
Mean age (P=.86) and the proportion of men and women (P=.73) did not change over
time (TABLE 2). The proportion of self-identified white or black patients with hypertension
did not change, and data were insufficient to assess changes in proportion of Hispanic
individuals with hypertension. Systolic and diastolic BP decreased between 1988-1994 and
2007-2008 (P for trend=.02 and P for trend <.001, respectively). The proportion of patients
with stage 1 hypertension (P=.002) and stage 2 hypertension (P =.03) decreased, but the
proportion of patients with prehypertension (P=.005) and normal BP increased. Mean BMI
increased over time (P=.01), as did the proportion of obese individuals (P=.04) and
individuals with diabetes (P=.006).
Awareness increased from 1999-2008 (P=.009) and 1988-2008 (P=.03) but was not
different between 1988-1994 and 1999-2000 (P=.88). The percentage of individuals with
hypertension who received treatment increased over time (P=.004), along with the percentage
of patients whose hypertension treatment controlled their BP (P=.006). Improvements in
awareness, treatment, and proportion of patients who were treated and whose BP was
controlled was associated with an increase in BP control to less than 140 mmHg and less than
90 mmHg among all patients from 27.3% (95% CI, 25.6%-29.1%) in 1988-1994 to 50.1%
(95% CI, 46.8%-53.5%) in 2007-2008 (P for trend=.006). However, BP control improved
significantly more in absolute percentages between 1999-2000 and 2007-2008 than between
1988-1994 and 1999-2000 (18.6%; 95% CI, 13.3%-23.9%; vs 4.1%; 95% CI ,0.5% to 8.8%;
P<.001).
To assess the effect of excluding the first BP measurement in determining mean
systolic and diastolic values, data were examined on 1810 individuals with hypertension in
NHANES 2007-2008 who had 3 measurements. Blood pressure decreased by 2.6/0.8 mmHg
(95% CI, 2.4-2.9/0.6-1.1 mmHg; P<.001/P<.001) between first and second reading and
3.6/1.1 mmHg (95% CI, 3.3-3.9/0.9-1.4 mmHg) between first and mean of the second and
third readings (P<.001/P<.001).

Clinical Epidemiology of Hypertension by Age Group
Prevalent hypertension increased over time in individuals aged 40 to 59 years (P=.02)
and 60 years or older (P=.04) but could not be assessed for those 18 to 39 years using
weighted linear regression (Figure1). Prevalent hypertension was greater among individuals
aged 60 years or older (P<.001) and 40 to 59 years (P<.001) than for those 18 to 39 years and
was more common in those 60 years or older than for 40 to 59 years (P<.001). Hypertension
awareness increased over time among individuals aged 40 to 59 years (P=.04) and 60 years or
older (P=.03) but not for 18 to 39 years (P=.36). Awareness was higher among individuals
aged 60 years or older (P<.001) and 40 to 59 years (P<.001) than for those 18 to 39 years but
was not different between the 2 older groups (P=.72).
The percentage of patients who were treated for hypertension increased among those
aged 40 to 59 years (P=.01) and 60 years or older (P=.03) but could not be assessed for 18 to
39 years. Treatment rates were higher among individuals aged 60 years or older (P<.001) and
40 to 59 years (P<.001) vs 18 to 39 years and 60 years or older vs 40 to 59 years (P=.03). The
proportion of patients who were treated and whose hypertension was controlled increased
over time among individuals aged 40 to 59 years (P=.02) and 60 years or older (P=.04) but
could not be assessed for those 18 to 39 years. The proportion of patients who were treated
and whose hypertension was controlled was lower among those 60 years or older than either
those 18 to 39 years (P<.001) or 40 to 59 years (P=.008) but was not different between 18 to
39 years and 40 to 59 years (P=.23).
Hypertension control increased over time among individuals aged 40 to 59 years
(P=.009) and 60 years or older (P<.001) but could not be assessed for those 18 to 39 years.
Blood pressure control was higher in those individuals aged 60 years or older (P<.001) and
40 to 59 years (P<.001) vs 18 to 39 years but did not differ between 60 years or older and 40
to 59 years (P=.62).
Data were generally insufficient (CEV>0.30) for weighted linear regression in
individuals aged 18 to 39 years, but the CEV was less than 0.30 for each of the variables in
Figure 1 for 1988-1994 and 2007-2008, which allowed performance of a weighted t test.
Between the first and last NHANES periods, hypertension prevalence did not change (P=.24),
where as awareness (P=.04), treatment (P<.001), the proportion of patients who were treated
and whose hypertension was controlled (P=.004), and the rate for hypertension control
(P<.001) increased.

Clinical Epidemiology of Hypertension by Race and Sex
Prevalent hypertension increased over time in black (P =.04) and white (P=.004) but
not Hispanic (P=.65) individuals (FIGURE 2). Prevalent hypertension was greater in black vs
white (P<.001) and Hispanic individuals (P<.001) but not different between white and
Hispanic groups (P=.12). Hypertension awareness increased among black (P=.006), white
(P=.04), and Hispanic (P=.03) individuals and was greater in black vs white (P=.004) and
Hispanic (P<.001) individuals and white vs Hispanic individuals (P=.03).
The proportion of patients with hypertension receiving treatment increased among
black (P<.001), white (P=.008), and Hispanic (P=.01) individuals. The proportion of
individuals who were treated for hypertension was greater among black vs white (P=.009)
and Hispanic (P<.001) and higher in white vs Hispanic (P=.006). The proportion of patients
who were treated and whose hypertension was controlled increased among white (P=.004),
black (P=.02), and Hispanic (P=.002) individuals and was higher in white vs black (P<.001)
and Hispanic (P=.02) but not different in black vs Hispanic (P=.08).
Controlled hypertension increased over time among white (P=.007), black (P=.008),
and Hispanic (P=.003) individuals. Blood pressure control was greater in white vs Hispanic
(P=.004) individuals but did not differ between black vs white (P=.11) or black vs Hispanic
(P=.09) individuals.
Prevalent hypertension increased over time in men (P=.04) but not women (P=.10)
and was not different between men and women (P=.37). Hypertension awareness increased
with time in men (P=.04) but not women (P=.09) and was greater in women than men
(P=.007). Hypertension treatment increased with time in women (P=.03) and men (P=.004)
and was higher in women vs men (P=.001). The proportion of patients treated and whose
hypertension was controlled increased in men (P<.001) but only marginally in women
(P=.05) and was greater in men vs women (P=.02). Controlled hypertension increased with
time in women (P=.04) and men (P<.001) but did not differ between groups (P=.33).

COMMENT
Hypertension control improved from 27.3% in 1988-1994 to 50.1% in 2007-2008 (P
for trend=.006). Hypertension control represents the product of awareness, the proportion of
aware patients who were treated, and the proportion of treated patients whose BP was
controlled (systolic BP of <140 mmHg and diastolic BP of <90 mmHg). The progress in BP
control reflected increases in awareness (P=.03), treatment (P=.004), and proportion of
patients with hypertension treated and controlled (P=.006).
In 2003, achieving the Healthy People 2010 goal of controlling BP in 50% of all
patients with hypertension appeared unlikely, given the relatively limited improvement
between 1988-1994 and 1999-2000. We proposed that increasing BP control from 31% in
1999-2000 to 50% by 2010 could be accomplished with substantial but achievable increases
in hypertension awareness, treatment, and proportion of patients with hypertension treated
and controlled from 69%, 58%, and 53% in 1999-2000 to 80%, 72%, and70%, respectively.
The 2003 projections closely approximated actual 2007-2008 NHANES mean estimates of
awareness (80.7%; 95% CI, 78.1%-83.0%), treatment (72.5%; 95% CI, 70.1%-74.8%), and
proportion of patients whose hypertension was treated and controlled (69.1%; 95% CI,
65.7%-72.3%). The improvement in hypertension control from 1999-2008 was significantly
greater than from 1988-2000 (P<.001).
The increase in hypertension control coincided with a significant decrease of systolic
and diastolic BP among patients with hypertension between 1988-1994 and 2007-2008
(P=.02 and P<.001, respectively). Healthy lifestyles are an unlikely explanation for lower BP
and better control among patients with hypertension, because eating patterns became less
DASH-like and obesity increased over time. Obesity is a characteristic of individuals with
treatment-resistant hypertension (ie, BP not controlled by >3 antihypertensive medications or
controlled by >4 BP medications). Despite challenges in controlling BP in patients who are
obese, control improved significantly in all obese patients but not in all non obese patients
with hypertension from 1999-2004. In addition to a greater percentage of patients receiving
treatment, data suggest that patients with hypertension, especially obese individuals, are
receiving more BP medications to explain the increase in proportion of patients who were
treated and controlled. Our study did not include detailed treatment analyses to assess this
possibility.
Systolic BP decreased over time in individuals with hypertension but increased
among individuals without hypertension (P=.02). Adverse changes in nutrition and obesity
are likely contributors to higher BP among individuals without hypertension. The prevalence
of hypertension is an important public health concern with a Healthy People 2010 goal of
16%. Prevalent hypertension increased between 1988-1994 and 1999-2000 (P<.001), but did
not change between 1999-2000 and 2007-2008 (P=.24), and remains much higher than the
national goal. From one - fifth to four fifths of the increase in prevalent hypertension
between 1988-1994 and 1999-2004 was at tributed to higher BMI.
Time trends in hypertension prevalence, awareness, treatment, and control among all
individuals with hypertension were documented in most demographic subsets in our study.
Sample size was generally in adequate among individuals aged 18 to 39 years for weighted
linear regression to assess changes over the 6 NHANES 1988-2008 groups. Sample sizes for
this group were adequate for weighted t tests comparing 1988-1994 with 2007-2008 and
showed significant improvement in the proportion treated (P<.001), patients with
hypertension treated and controlled (P=.004), and the proportion whose hypertension was
controlled (P<.001). Awareness and treatment were greater in patients with hypertension
aged 60 years or older (P<.001) and 40 to 59 years (P<.001) vs those 18 to 39 years. Our
findings coincide with another NHANES report that adults aged 20 to 39 years were less
aware of hypertension than older individuals. Poverty and health insurance were not
characteristics of individuals who were unaware of their hypertension, although they were
more likely to receive only to 1 health care visits in the prior year. In our study, individuals
with hypertension aged 18 to 39 years were more likely to attain control when treated vs
those 60 years or older (P<.001). Data suggest efforts to improve BP control in younger
adults should focus on raising awareness and linkage to a primary care medical home.
Among patients aged 60 years or older, hypertension awareness and treatment were
relatively high, where as the proportion of patients with hypertension treated and controlled
was lower compared with those 18 to 39 years (P<.001) and 40 to 59 years (P=.008).
Although our study did not focus on treatment details, older age is a key patient characteristic
in treatment-resistant hypertension. Strategies for enhancing treatment effectiveness
(proportion of patients with hypertension treated and controlled) emerge as an important
factor for improving hypertension control among individuals older than 60 years. While BP
control is important, treatment of hypertension in older patients reduces cardiovascular
events, even when mean treated systolic BP remained higher than 140 mmHg.
Hypertension awareness, treatment, proportion of patients with hypertension treated
and controlled, and the proportion with hypertension controlled improved over time in white,
black, and Hispanic groups, but significant disparities persist. The greater prevalence of
hypertension in black vs white (P<.001) or Hispanic (P<.001) individuals is well
documented. Awareness of hypertension was higher among black vs white (P=.004) and
Hispanic (P<.001) individuals, and white vs Hispanic individuals (P=.03). Similarly,
treatment rates were higher in black vs white (P=.009) and Hispanic (P=.006) individuals,
and white vs Hispanic (P=.006) individuals. A different pattern emerged for the propotion of
patients whose hypertension was treated and controlled, with higher rates among white vs
black (P<.001) or Hispanic (P=.02) individuals. Data suggest that initiatives to improve BP
control among Hispanic individuals should emphasize screening and referral to a primary
care medical home, where as more emphasis on treatment effectiveness is needed for black
individuals.
Hypertension awareness and treatment are higher in women than in men, and the
proportion of patients treated and controlled was higher in men vs women. NHANES data
suggest that raising hypertension awareness and treatment is important formen, where as
controlling hypertension in patients who are treated is a higher priority for women.
Our study has limitations. Sample size for detecting changes among individuals aged
18 to 39 years was limited and required t tests of the first and last NHANES surveys rather
than weighted linear regression encompassing all 6 surveys used for all other demographic
groups. The guidelines recommend confirming stage 1 (mild) hypertension at follow-upvisits.
Blood pressure on a single NHANES assessment may overestimate prevalent hypertension.
Blood pressure was measured by a physician and typically provided higher values than
measurements by nurses, which would tend to over estimate prevalent hypertension and
underestimate control. Because out-of-office BP is not available in most NHANES
participants, we excluded the initial reading, which is often the highest value, when ever 2 or
more BP measurements were available. Blood pressure decreased significantly between first
and second reading and between first and mean of the second and third reading, which served
to attenuate the physician BP effect. Despite limitations, BP has been consistently measured
during NHANES 1988-2008. Methods for assessing prevalence, awareness, treatment, and
control were also consistent, which strengthens the validity of comparisons over time.
Inconclusion, hypertension control improved, with most of the progress toward the
Healthy People 2010 goal of controlling BP in 50% of all individuals with hypertension
occurring between 1999 and 2008. However, prevalent hypertension is not decreasing toward
the national goal of 16% and will likely remain high unless adverse trends in population
nutrition and BMI occur or pharmacological approaches to hypertension prevention are
adopted.
Hypertension control improved, despite adverse changes in nutrition and BMI, and
reflects increases in awareness, treatment, and patients who were treated at taining target BP,
in all individuals with hypertension combined and all age, race, and sex subgroups. However,
demographic disparities exist. Broad-based efforts to improve awareness, treatment, and
proportion of patients treated and controlled are important for increasing BP control in all
groups. Complementary programs to raise awareness and treatment among 18 to 39 years,
Hispanic, and male groups and to increase the proportion of patients treated and controlled
among 60 years or older, black, and female groups are important for improving hypertension
control and reducing disparities.